Dysphagia Management in the Frail Elder Joseph Murray, PhD, CCC-SLP, BCS-S VA Ann Arbor Healthcare System Current Expectations Upon Consultation Determine need for assessment Choose the appropriate tool for the assessment Observe events and infer disordered physiology of swallow. Design appropriate treatment plan to address the disorder Speech Pathology Most Frequent Solicitation Determine presence of aspiration Determine if PO intake of food and/or medications is possible Based on assumption Nothing enters the mouth Nothing can enter the lungs There is no pass/fail! Alternate Questions What is the: · Risk for poor outcome? · Ability to maintain nutrition/hydration via oral feeding? · Plan for management of safety and vitality? · Means for improving physiology? Alternate Questions How can we: Plan/manage decline and compensation? Determine means for ensuring quality of life? Literature Is Not Sufficiently Developed to Answer These Questions! Aging and Frailty Frailty A clinical state of vulnerability to stressors results from aging-associated declines in resiliency and physiologic reserves a progressive decline in the ability to maintain a stable homeostasis Failure to Thrive Pediatric Patient has not attained functional status. Geriatric Patient has not maintained functional status. Failure to Thrive in Children Failure to thrive (FTT) describes children who exhibit growth deficiency indexed by faltering or stunted growth. FTT is associated with: poorer cognitive development learning disabilities long-term behavioral problems. Failure to Thrive in Children Often blamed on maternal factors young age low income Stress cognitive impairment emotional problems Findings have not been supported in most controlled studies Failure to Thrive in Children Non-organic causes Poverty Protein energy malnutrition Kwashiorkor Marasmus Fear of obesity/health problems Voluntary restriction of calories Parental control of calories Factitious food allergy Failure to Thrive in Children Organic Causes Cerebral palsy Bronchopulmonary dysplasia Congenital heart disease Enzyme deficiency Secondary symptoms of disease Esophageal Reflux Dysphagia Frailty Incidence in the Elderly 10% to 20% of persons older than 65 years of age are frail 46% of community-dwelling persons older than 85 are frail 985 patients admitted to the Palo Alto VA older than 65 27% were judged to be frail 45% 1-year mortality rate Incidence of frailty increased 4.8% of 65-year-olds 56.3% for 90-year-olds Genesis of Frailty Failure of communication between multiple physiologic systems Neuromuscular Organs Cellular Molecular Leads to physical dysregulation Nutrition and Muscle Energy expended at a rate of approximately 1,800 kilocalories/day. Nutrients for energy expenditure supplied in glucose Maintains basic function of: brain blood muscle The brain alone metabolizes 100 to 150g of glucose (Ferrendelli, 1974) Catabolism and Anabolism Catabolism describes the breaking down of cells into smaller units Creation of amino acids from proteins Anabolism describes the construction of complex cells from smaller units Conversion of glucose from amino acids Building up of muscle, tissue and organs Anabolism is powered by catabolism Catabolism Glucose from Carbohydrates Carbohydrates Rapid release of simple glucose in the lumen of the duodenum and small intestine Glucose transported via the bloodstream to the organs Glycogenolysis Unused glucose makes its way to the liver and muscles Stored as glycogen Fat Cells Glycogen is the body's auxiliary energy source Tapped and converted back into glucose when there is need for energy. Catabolism Glucose Production from Protein Enters through the enteral tract Creation of amino acids Absorbed by the gastrointestinal tract Carried to the liver Amino acids synthesized in the liver to create glucose Delivered to organs for energy Aging and Muscle Sarcopenia From the Greek sarx for flesh and penia for loss Age-associated loss of muscle mass and function (Rosenberg, 1989). Sarcopenia Generalized withdrawal of the neurotransmitters (Roubenoff, 2003) Failure to stimulate anabolic reactions that result in muscle regeneration Stimulation of catabolic reactions Increased gluconeogenesis Sarcopenia A degree of muscle loss is expected with age Frail elder with sarcopenia Muscle loss beyond the volume expected in peers Dramatically less muscle than younger normals. Prevalence of sarcopenia in <65 yrs 6% to 15% (Melton, Khosla & Riggs, 2000). Sarcopenia in Aging (Iannuzzi-Sucich, Prestwood & Kenny, 2002). >80 years of age >30% of women >50% of men Independent predictor of Poor gait Poor balance Falls Fractures. Gender and Sarcopenia Janssen, Baumgartner and Ross (2004) Women with sarcopenia 3.3 times more likely to have physical disability Men 4.7 times more likely to have physical disability. Sacopenic Obesity Increase in catabolism Greater than increase in protein synthesis from feeding Weight maintained or gained Leads almost solely to fat accumulation. Baumgartner et al. (2004) Combination of sarcopenia and obesity More strongly associated with disability than either body composition type (sarcopenia or obesity) alone. Symmorphosis Size and strength of physiologic components Must match overall functional demand Must cope with the highest expected functional demands Must include some safety margin to prevent the system from failing when it is overloaded Functional Reserve Most body systems 30% of normal function represents a threshold for adequate function OR 70% margin of loss before evidence of failure presents. Functional Reserve Example: Lower Extremity Strength Young subjects 5 W/kg muscle power in the legs To walk, 1.2 W/kg is required (24% of baseline) Below 0.5 W/kg (10% of baseline) movement becomes impossible Functional Reserve in the Elderly Reduction in functional reserve expected in the elderly Maximum isometric and minimum required closer together Narrowing progresses throughout late life Less room to accommodate stressors that require reserve (I.e. Falls, Sickness) Frailty observable when functional reserve cannot accommodate the “stressor” Considerations for the Frail Elder with Dysphagia What makes the elderly different? Swallowing physiology changes with increasing age Video examples Nilsson, H., Ekberg, O., Olsson, R., & Hindfelt, B. (1996, Summer). Quantitative aspects of swallowing in an elderly nondysphagic population. Dysphagia, 11(3), 180-186. Increased oral and pharyngeal transit times Longer duration of pharyngeal pressures Higher incidence of pharyngeal residue after swallowing Nicosia, M.A., J.A. Hind, E.B. Roecker, M. Carnes, J. Doyle, G.A. Dengel, and J. Robbins. “Age Effects on Temporal Evolution of Isometric and Swallowing Pressure,” Journal of GerontologyMedical Sciences, Nov. 2000. Differentiated age-related alterations in swallowing physiology from disease-related changes. Focused on tongue physiology Derived data from three-bulb tongue manometrics and simultaneous fluoroscopy. Nicosia et al. 2000 Age Effects decreased maximum isometric pressure unchanged maximum swallowing pressure increased time to reach peak isometric pressure increased time to reach peak swallowing pressure change in pattern of lingual pressure generation with increased age Considerations for the Frail Elder Medical Diagnoses Physical Function Social Support Environment Medical Components of Frailty Cancer Diabetes Heart Disease Infections Hyperthyroidism Polypharmacy Alcoholism Organ Failure COPD Stroke Functional Components Functional Causes Immobility Sensory Impairments Dental problems Langmore et al. 1998 Odds Ratios for Aspiration Pneumonia Dependent for feeding Dependent for oral care Number of decayed teeth Tube feeding Dysphagia was an important risk for aspiration pneumonia but generally not sufficient to cause pneumonia unless other risk factors were present Dental Plaque One cubic millimeter of dental plaque contains about 100 million bacteria Oral bacterial load increases during intubation Higher dental plaque scores predict risk of pneumonia Munro CL, Grap MJ, Elswick RK Jr (2006). Oral health status and development of ventilator-associated pneumonia: a descriptive study. : 453–460. Full diversity of oral flora is unknown Maybe unknowable Site Specificity Secretory Immunoglobulins Heavy plasma proteins Recognize pathogens Bind with protiens in the pathogen Kill it directly Block and bundle toxins Mucins “Slimy“ stuff in mouth Proteins coats many epithelial surfaces Secreted into saliva Serves as a diffusion barrier against contact with noxious substances Lubricates to minimize shear stresses Super lubricant! GOMES-FILHO, I., PASSOS, J., SEIXAS DA CRUZ, S.. Respiratory disease and the role of oral bacteria. Journal of Oral Microbiology, North America, 2, dec. 2010. Biological mechanisms involved between oral conditions and respiratory diseases Four possible mechanisms Oral pathogens directly aspirated into the lungs Salivary enzymes associated with periodontal disease modify respiratory tract mucosal surfaces Enzymes from periodontopathic bacteria destroy salivary film that protects against pathogenic bacteria Cytokines Oral pathogens directly aspirated into the lungs Pseudomonas aeruginosa Ventilator acquired pneumonia with P. aeruginosa Opportunistic pathogen with ability to develop resistance to antibiotics higher mortality compared with other pathogens Chastre J, Fragon J-Y. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165:867–903. Increased colonization of the oropharynx of patients with nasogastric tubes Leibovitz A, Dan M, Zinger J, Carmeli Y, Habot B, Segal R. Pseudomonas aeruginosa and the oropharyngeal ecosystem of tube-fed patients. Emerg Infect Dis 2003;9:956–959 El-Solh, A et al. Colonization of Dental Plaques*: A Resevoir of Respiratory Pathogens for Hospital-Acquired Pneumonia in Institutionalized Elders Chest; November 2004 Vol 126(5) pp 1575-1582 Association between dental plaque colonization and lower respiratory infection in elderly using molecular genotyping 49 Critically ill LTC residents requiring ICU Plaque index scores Quantitative cultures BAL on 14 patients who developed pneumonia Respiratory pathogens compared genetically to plaques by pulse gel electrophoresis El-Sohl et al. cont 28/49 (57%) had colonization of plaque with aerobic pathogens Staphylococcus aureus (45%) Gram-negative bacilli (42%) Pseudomonas aeruginosa (13%) Isolates from BAL fluid 9/13 matched genetically those recovered from corresponding dental plaques of 8 patients Yoneyama T, Yoshida M, Ohrui T, Okamoto H, Hishiba K et al. (2002) Oral care reduces pneumonia in older patients in nursing homes Journal of the American Geriatrics Society,50 3 430 417 patients randomly assigned to one of two groups Oral care group No oral care group Yoneyama et al. (2003) Oral Care Group Nurses or caregivers cleaned the patients' teeth by toothbrush after each meal. Swabbing with iodine was additionally used in some cases. Dentists or dental hygienists provided professional care once a week. Significant decrease in: Pneumonia febrile days death from pneumonia Scannapieco, Paju and Bush Annals of Periodontology, Vol 8, Number 1, 54-69 December 2003 Review of periodontal disease and nosocomial pneumonia 21 case control and cohort studies 9 RTCs Oral colonization is associated with nosocomial pneumonia Oral interventions improving hygiene reduced incidence of nosocomial pneumonia by an average of 40% Terpenning M, Taylor GW, Lopatin DE, et al. Aspiration pneumonia: dental and oral risk factors in an older veteran population. J Am Geriatr Soc 2001; 49:557-563 134 Geriatric patients Dentate patients with pneumonia 27% of inpatients 19% of LTC Edentulous patients with pneumonia 5% Hand Dexterity and Oral Hygiene Padilha DMP, Hugo FN, Hilgert JB . Hand function and oral hygiene in Brazilian institutionalized elderly. J Am Geriatr Soc 2007;:1333–1338. 49 institutionalized participants 29 dentate 36 one complete denture Poor hand function (Purdue Test of Dominant Hand Function) Dentate Correlated with significantly more dental plaque Complete denture wearers Correlated with significantly more denture plaque Who Should Do It? Kenneth Shay, DDS, MS. (2007) Who Is Responsible for a Nursing Home Resident's Daily Oral Care?. Journal of the American Geriatrics Society :9, 1470–1471 Costs are also high for: Bathing Toileting Feeding What About Aggressive Oral Hygiene? Simons D, Kidds EA, Beighton D. Oral health of elderly occupants in residential homes [letter]. Lancet 1999; 353:1761 Health-care providers in residential homes give little assistance with tooth and denture cleaning Simons D, Baker P, Jones B, et al. An evaluation of oral health training programme for carers of the elderly in residential homes. Br Dent J 2000; 188:206-210 Even if training and education are provided! Social Causes Isolation Loss of spouse Exhaustion of care giver Low-socioeconomic status Social Support and Poor Nutrition Associated Difficulties Difficulty shopping Difficulty with meal preparation Poor appetite Additional stressors Weight loss Dehydration Severe constipation Vigilant Observation Ongoing assessment/observation of the whole patient Mental Status Cognition Voice Speech/Articulation Gross motor function/mobility Instrumental Signs Generalized weakness Retained bolus Reduced frequency of swallowing No specific pattern to retention With retained bolus Silent aspiration 3 Stages of Swallowing Should include “readiness to eat” Circadian cues Neurotransmitter stimulus Social cues Auditory cues Pre-food preparation Gustatory cues Discussion of “what to eat” Olfaction Tasting Synergy of the stimuli Missing in institutionalized elders PEG Tube Placement Introduced in 1980 as a safe and effective alternative to open surgical gastrostomy (Gauderer et al., 1980) Less than 2% intra-operative complication rate Allowed TF in almost all cases Cost-effective for multiple providers and was presumed to be beneficial since poor nutrition was a known risk factor for worse outcomes PEGs quickly became the procedure of choice PEG Tube Placement Disturbing trends By 1999 34% of severely cognitively impaired in US NHs had PEGs (Mitchell et al., 2003) High 6-month mortality rates associated with cancer, dementia, and neurodegenerative disease as well as racial disparities, with blacks receiving tubes at nearly twice the rate of whites (Grant et al., 1998; Verhoef & Van Rosendaal, 2001) Cultural Differences at End of Life Phipps, E.,True, G., Harris, D., Chong, U., Tester, W., Chavin, S., Braitman, L. (2003) Approaching the End of Life: Attitudes, Preferences, and Behaviors of AfricanAmerican and White Patients and Their Family Caregivers. Journal of Clinical Oncology, 21, 549-554 Phipps et al. 2003 White patients more likely: Have durable power of attorney (34% v 8%, P = .01) and Have a living will (LW; 41% v 11%, P = .004) African-American more likely: To use of life-sustaining measures (cardiopulmonary resusitation [CPR], mechanical ventilation, tube feeding) in their current condition (all P > .12) Phipps et al. 2003 Near-death condition African-Americans more likely To desire life-sustaining measures (all P < .004) Patient Caregiver agreement For those without living wills: CPR 46% Mechanical ventilation 50% Tube feeding 43% Desired Life Support Measures Phipps et al. 2003 Cardiopulmonary Resuscitation White Patient Care Giver ** P<.01 * P<.05 31% 45% AA Enteral Tube Feeding White 73%** 71% * 17% 55% 62% Mechanical Ventilation AA White 53%** 21% 33% 44% AA 58%** Phipps et al. 2003 Reasons for not having completed any formal documentation: Concerns about the emotional distress for either self or family Feeling that they did not need to engage in advance care planning View that the initiative for advance care planning needed to come from someone else Highlights the importance of clinicians bringing up advance care planning with their patients Patients and families may be fearful of discussing the topic May be waiting for some one else to initiate discussion May be relieved when someone does MODI, S., WHETSTONE, L., CUMMINGS, D., (2007) Influence of Patient and Physician Characteristics on Percutaneous Endoscopic Gastrostomy Tube Decision-Making. JOURNAL OF PALLIATIVE MEDICINE Volume 10, Number 2 Survey of physicians 981 Caucasian, African-American Asian Given hypothetical case scenario involving an elderly female patient with advanced dementia and weight loss presenting to the office for routine follow-up with her daughter Two versions of survey with patient as AA or Caucasian Recommendations for PEG tube placement Caucasian physician 13.0% Asian physician 54.3% African American physician 40.0% p 0.001 African American physicians recommended PEG for African American patient 51.4% for Caucasian patient 24.0% Mebane EW, Oman RF, Kroonen LT, Goldstein MK: The influence of physician race, age, and gender on physician attitudes toward advance care directives and preferences for end-of-life decision-making. J Am Geriatr Soc 1999;47:579–591. Paper suggests that African American physicians more likely : To believe that length of life is more important than quality of life To desire tube feeding and other aggressive measures for themselves are less likely to view tube-feeding as a “heroic” measure Modi et al. 2007 One interpretation: Results may indicate that physicians provide care to their patients that they themselves would want, especially to patients who appear similar to themselves Another interpretation: AA physicians are more in tune with the variation in ethnic orientation to end-of-life care More likely to predict patient and family wishes Burdens and Complications Associated with PEG Wound dehiscensce Skin excoriation Tube migration Pain at tube site Diarrhea Nausea Loss of gustatory pleasure Restraint use Aspiration GER Abdominal abscess GI bleeding Loss of social interaction Peritonitis Tube malfunction Necrotizing fasciitis Bowel obstruction Vomiting Pneumonia Gastric performation The Clinical Evidence PEG has been associated with benefit in only a handful of conditions PEG has been shown to improve QOL but not mortality in head and neck cancer (Santori et al., 1996) In ALS, PEG use has been shown to improve QOL scores and weight but nor mortality (Mitsumoto at al., 2003) Pts with bulbar ALS with improved survival and QOL (Mazzini et al., 1995; Miller, 2001) The Clinical Evidence May improve survival among pts in a permanent vegetative state (NEJM, 1994) Prolongs lives of pts with extreme shortbowel syndrome (Scolapio et al., 1999) The Clinical Evidence Early Evidence: PEG placement after stroke decreased mortality, treatment failures and malnutrition (Norton et al., 1996; Duncan et al., 1992) Clinical Evidence More recent Cochrane review (2005) “too few studies have been performed, and those have involved too few patients.” 2005 FOOD trial No benefit to early vs. delayed PEG feeding Increased risk of death Poor neurologic outcome with PEG compared to NG use FT in Advanced Dementia (Ficune et al., JAMA 1999) Does not improve nutritional status Does not prevent aspiration Does not reduce occurrence of pneumonia Does not increase life expectancy Enteral tube feeding in older people with advanced dementia: Findings from a Cochrane systematic review (Candy et al., 2009) Full literature review completed in April 2008 No RCTs were identified 7 observational studies: 0 studies examined effect on QOL and No evidence of benefit 6 assessed mortality (no evidence of increased survival with enteral feeding) Nutritional status Prevalence of pressure ulcers Conclusions: Insufficient evidence to suggest that enteral TF is beneficial in people with advanced dementia Data is lacking on the adverse effects of this intervention SLP Misconceptions About PEG in Advanced Dementia (Sharp & Shega, 2009) Survey of 1,050 medical SLPs Describe beliefs and practices about use of PEG in pts with advanced dementia Response rate of 57% 56% of SLPs recommend PEG Many believe that PEG improves nutritional status and increases survival Relatively few believed that PEG improves nutritional status and increases survival 40% believed that PEG was standard of care 15% believed it should be standard of care Only 11% of SLPs would want a PEG themselves Is Dysphagia a Terminal Symptom? (Regnard, Leslie, et al., 2010) In Alzheimer’s dementia Dysphagia can occur early in the disease process Is not always a terminal symptom as commonly believed (Preifer et al., 1997; Royal College of Physicians and the British Society of Gastroenterologist, 2010) Can be missed Poor screening Atypical presentations Care provider adjustments to its presence Are PEGs Inserted Too Late? Delayed identification increases risk of malnutrition Patients with low albumin do worse than those with normal albumin following PEG (Nair et al., 2000) SLP Goals of Intervention (Eckman & Roe, 2005; Pollens, 2004) Assist in the minimization of risks and symptoms of aspiration Maximize the pts comfort and satisfaction when eating and drinking Traditional Goals/Outcomes of Tube Feeding 1. 2. 3. 4. Improve nutritional status Decrease risk of disease Increase length of survival Improve comfort/quality of life Medical Management of Symptoms that Affect Swallowing and Nutrition Pain Fatigue/Asthenia Constipation Dyspnea Nausea Vomiting Delirium Depression/suffering DYSPHAGIA 80-90% 75-90% 70% 60% 50-60% 30% 30-90% 40-60% ????? Communication in Decision Making Vital skill Enteral feeding decision are often a “crisis” for families Stress Fear Intimidation Unfamiliarity with the setting Professional Roles in Communication Professionals are responsible Minimum Attempting to communicate Ensuring that effective communication takes place Stressful for physicians and allied health Professional Roles in Communication Requires time Often in short supply. Factual knowledge of what is to be communicated Ethical choice about how such information is Selected Ordered Expressed Professional Roles in Communication Esoteric vocabulary may intimidate Inappropriate tone or gestures can offend Establishment of empathy may demand a profound cultural understanding Communication of verbal and written information Many patients with oral feeding difficulties have communication or cognitive disabilities which affect understanding, retention and processing of verbal and written information and communication of needs Ensure that appropriate measures have been taken to enable participation in discussions and decision making Practical Communication Be aware of any communication and cognitive impairments Familiarity with how the patient communicates Communication aids Spelling/picture boards Hearing aids Strategies Drawing Gesture Practical Communication Use trained interpreters to speak to patients where English is not understood Accessible written and pictorial information left to be read at leisure Leaflets Oral feeding Alternative nutrition Videofluoroscopy/FEES Meal selection Practical Communication Allocation of sufficient time for explaining information Limitation of information given in one session; Several short conversations are better than one lengthy session Information to be repeated to aid comprehension Opportunity to ask questions Quiet, private environment free from distractions Choice of an appropriate time of day iIf the patient is too tired by the afternoon, wait till the morning Find out whether the patient wants anyone to join them, eg a family member Non-verbal communication Communication is not always about factual information May need to express solidarity with a fellow human being Frequent attendance at the bedside may prevent perception patient is being abandoned Nature/mode of death if nutrition is withheld The consequences of malnutrition Lethargy/apathy Impaired muscle function leading to immobility Hypostatic edema Respiratory muscle failure Pneumonia Myocardial muscle dysfunction Thromboembolism Impaired temperature control Falls Pressure sores Nature of death if nutrition and hydration witheld Death occurs rapidly Renal failure Pneumonia. It is commonly believed that death from absent nutrition or hydration is distressing or painful for the patient. This may be true with better cognitive function Appetite is often severely reduced in terminal disease sensations of hunger and thirst are suppressed Severely cognitively impaired little evidence that hunger or thirst are perceived significantly may resist the efforts by care givers to offer food or fluids Rejections may be no more than reflex responses Alternatives to ANH: social feeding – oral feeding techniques Rigidity of mealtimes and other issues have been identified as problems. Malnutrition in hospitals may result from poor timing and delivery of nutrition Restlessness that may increase metabolic need in patients with dementia Patients forget about meals Forget what food is How to eat it Responses to Problem Feeders: Allowing the person more time to feed him/herself Quiet mealtimes with opportunity to eat supported by adequate staff time More flexible mealtimes so the patient can feed when they want to Feeding the patient either some of the time or all of the time Responses to Problem Feeders Special training for staff in administering food and fluids Structuring staff duties to deliver proper nutritional support Care planning of feeding and nutritional support Prioritization of weighing and other nutritional monitoring support Increasing meal frequency Concentrating on the midday meal in dementia, which has been shown to provide the greatest calorie intake Examples of Criteria for Success of Enteral Feeding: Decrease in discomfort/symptoms as medication can be given more readily Increase in weight if the patient is underweight Improvement of healing of pressure ulcers Increased capacity for rehabilitation Reversal of confusion Negative Aspects of PEG Placement Invasive Medical risks of placement Reflux Even in the best units 30-day mortality is 6% 10% morbidity Negative Aspects of PEG Placement Social Individual is attached to a pump for up to 20 hours per day May require repeated bolus administration Less social interaction Significant alteration in body image Legal risks: against wishes Deprived of pleasure of eating Meok-Bang Television Hugely popular Korean internet phenomenon Name is mash-up of two Korean words Eating (meok-guh) Broadcast (bang song) Enhances eating experience Emulates communal eating Audience Singles Elders People eat more when watching others “eat Community Model Dining Increase Accessibility to Food -Real foods should be available 24 hours/day-snack carts or kitchenettes with snacks residents enjoy such as animal crackers, suckers, raisins, granola bars, crackers, popcorn, etc. -Include a bread machine and/or crock pot of soup in the veteran’s dining rooms/kitchenettes for the aroma/sensory stimulation and to serve at the beginning of meals. -Counter tops wheel chair accessible so residents could participate in cooking if they desire. -Having 2 breakfasts, an early am and a brunch time. Involve everyone at meal times, like home. -All disciplines assist in serving the meal and feeding the residents, including, nursing, social work, recreation therapy, etc. -Food eaten on place mate or table cloth, with centerpiece.
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